Mind the gap


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Mind the gap: ways to enhance therapy provision in stroke rehabilitation
This document, being launched at the UK Stroke Forum this week, explores some of the different models adopted by therapy services to deliver more rehabilitation and provides further detail about 45 minutes, process and outcomes.
(Published November 2011)

Published in: Health & Medicine
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Mind the gap

  2. 2. AcknowledgementsAuthors: With additional thanks for their support, contributions and comments to:Jill Lockhart, National Improvement Lead,NHS Improvement - Stroke Professor A Rudd, Stroke Physician, Guy’s and St Thomas’ HospitalIna James, Team Leader Physiotherapist, StrokeServices, York Hospitals NHS Foundation Trust Professor V Pomeroy, Professor of Neurorehabilitation, University of East AngliaGail Linstead, Stroke Service ImprovementManager, North of England Cardiovascular National rehabilitation projects 2009-10Network Therapy Teams from Medway Healthcare and York NHS Foundation TrustWith considerable thanks to the NHSImprovement - Stroke Increasing Access to Brighton Paradza, Senior Clinical SpecialistTherapy National Project Teams: Physiotherapist, Cardiothoracic Acute Services, The James Cook University HospitalSheffield Teaching Hospitals NHS FoundationTrust, Stroke Therapy Service Fiona Lunn, Nurse Consultant Stroke and the Stroke Team at University Hospital of NorthSheffield Primary Care Trust Speech and Staffordshire NHS TrustLanguage Therapy Service into SheffieldTeaching Hospitals NHS Foundation TrustThe Stroke Unit at St Thomas’ Hospital, Guysand St Thomas’ NHS Foundation TrustNewton Abbot Hospital Teign Ward andTorbay and Southern Devon Care Trust StrokeTherapy Team and Community NeurologyService Team, South DevonNHS Camden - stroke REDs teamThe community stroke team in Blackburnwith Darwen, part of Lancashire Care NHSFoundation TrustSouth Tyneside NHS Foundation TrustPhysiotherapy Stroke TeamStroke Rehabilitation Unit, St Bartholomew’sHospital, Rochester, Kent, MedwayCommunity HealthcareChesterfield Royal Hospital NHS FoundationTrust Acute Stroke Unit Team
  3. 3. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationContents4 Foreword5 Executive summary6 Introduction8 National guidelines10 Who can deliver more rehabilitation?14 When - a seven day service?17 How long - getting more out of the whole week?22 Where can more therapy make a difference?24 How - bridging the gap?28 Conclusions30 References31 Case studies32 NHS Camden – stroke REDs Improving access to 45 minutes of therapy for stroke patients36 The community stroke team in Blackburn with Darwen, part of Lancashire Care NHS Foundation Trust Retrospective evaluation of therapy need and provision37 Medway Community Healthcare Stroke Rehabilitation Unit, St Bartholomew’s Hospital, Rochester, Kent Improving access to 45 minutes of therapy for stroke patients39 South Tyneside NHS Foundation Trust Increased stroke physiotherapy provision on stroke wards40 Sheffield Teaching Hospitals NHS Foundation Trust Implementing seven day occupational and physiotherapy services for stroke42 Sheffield Primary Care Trust and Sheffield Teaching Hospitals NHS Foundation Trust Sheffield stroke unit seven day working pilot for speech and language therapy43 Chesterfield Royal Hospital NHS Foundation Trust Developing a seven day physiotherapy service on the acute stroke unit44 Newton Abbot Hospital stroke unit with Torbay and Southern Devon Care Trust South Devon Stroke Services: Seven day working and 45 minutes of therapies46 Guys and St Thomas’ NHS Foundation Trust Seven day service: Weekend rehabilitation support worker model48 Stoke-on-Trent: University Hospital of North Staffordshire NHS Trust49 Stakeholders 3
  4. 4. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Foreword One thing we have learnt from implementation of the National Stroke Strategy is that the NHS cannot be a Monday to Friday service any more for people who have had a stroke. The faster you act, the more of the person you save is the mantra for the medical emergency response, and increasingly, we are seeing this is what is needed for therapy services too. The NICE Quality Standards for Stroke gives therapists a standard to work to for the first time. This report gives you lots of ideas and methods to get started to make those standards a reality. It’s going to require hard work and soul searching to think carefully about what you do now and what can be changed and improved. I urge you to embrace this as a way to describe what you do and ensure it is valued by everyone. In a stroke team, rehabilitation is everyones business. The teams featured in this report have learnt to share skills and to make rehabilitation the basis of the patient’s day. And that’s the key message. We must make sure the service works to meet the needs of the patient, not the other way around. Professor Sir Roger Boyle CBE 4
  5. 5. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationExecutive summaryIt is accepted that rehabilitation is anessential part of the management andtreatment for stroke survivors -“Rehabilitation afterstroke works. Specialistco-ordinated rehabilitation,started early after stroke andprovided with sufficientintensity, reduces mortalityand long-term disability.”National Stroke Strategy 2007There is much diversity across theshape, content and delivery ofrehabilitation and therapy servicesacross England and this presents achallenge for both serviceimprovement and research. All patients can have a rest day if it is Well organised and structuredThis project explored some of the appropriate, but it doesn’t always additional therapy services, delivereddifferent models adopted by therapy need to be Saturday or Sunday for over more days of the week impactservices to deliver more therapy/ every patient. Seven day therapy positively on patients and therapyrehabilitation in the context of major services enable equity of access and delivery (frequency and intensity)change within the NHS nationally and the opportunity for patients to begin across the whole week.locally. their treatment as early as possible. They support swifter multidisciplinary This work has, arguably, onlyThis publication discusses their effect team engagement and speedier scratched the surface of the issue ofon patients, services and organisations, progress, thereby capitalising on other therapy availability, yet hopefully,provides some useful learning to improvements to the front part of the provides useful ideas and insights.inform the debate with further detail stroke pathway. Meanwhile, seven day Project teams have shown the benefitabout 45 minutes, process and community stroke services can have of applying systematic serviceoutcomes and asks further questions more influence on hospital length of improvement analyses to theirfor therapy services to consider. stay than weekend therapy inpatient functioning, processes and patient services. outcomes. To support furtherThe commonly emerging themes were development, more scientific researchhow important it is to understand Access to, and delivery of, 45 minutes in this area is also crucial. It is worthexisting services fully by using therapy, improved when seven day noting that improved and efficientaccurate data and relevant data services were available and following services create an environment inanalysis, that managing human demand and capacity activity analysis which research can be betterdimensions is paramount with making across the pathway. This improvement facilitated and enabled, and ansuch huge cultural changes within brought different benefits reflecting effective research culture withintherapy services and the need to the service needs, patient stage of clinical services enhances their abilitycontinue optimising workforce recovery and their goals. All models to care for theircombinations and work collectively received very positive qualitative patients.along the pathway is essential to feedback from patients regardless ofdelivering effective responsive and who delivered it.timely services. 5
  6. 6. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Introduction There are many policy drivers for this project including the National Stroke Strategy (1), Royal College of Physicians (RCP) National Clinical Guidelines for Stroke (2), National Institute for Clinical Excellence (NICE) quality standards for stroke (3), and Care Quality Commission (CQC) report on stroke services (4). In addition, the requirement to improve quality and productivity to ensure services continue to meet demand within existing resources requires all services to review and maximise the use of their workforce. Therapy stroke services are facing increasing pressure as research suggests that their services deliver poorer outcomes, yet are better resourced than some European counterparts. (14) There is increasing pressure from commissioners to demonstrate the added value of specialist services, in comparison with generic ones. National standards set out the Project teams also wanted to expectations; however, services are understand more clearly which This can be viewed by therapists as a struggling to work out how to patients receive most therapy and why challenge to their services, or as an implement them. This publication this happens. The projects did not aim opportunity to examine practice summarises some practical service to examine the questions around ad objectively and pragmatically, gain a delivery solutions and the ways in hoc or formalised organisation of fuller understanding of how they can which these “Mind the Gap”. therapy services, whether more improve patient contact time and therapy improved clinical functional deliver higher quality rehabilitation Process of the projects outcomes, or the nature of the clinical across the stroke pathway. This would Aim approaches and modalities used. enhance the significant changes that The aim of this work was to: have already taken place in stroke care • Look at the impact of different and positively embrace the culture models that stroke services are using change required to deliver a to increase access to therapy and responsive, flexible, timely and rehabilitation relevant therapy service for stroke • Understand how to affect delivery survivors. of national quality standards, guidelines and aspirations for stroke services • See if there were any changes to treatment intensity or frequency, length of stay and other outcomes. 6
  7. 7. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationMethodology This publication builds on the learning • South Devon - A combined teamThere were two project streams: from project sites in the national of therapists on the stroke1. Delivering 45 minutes of rehabilitation projects 2009-10 (25) by rehabilitation unit at Newton Abbot therapy further work with the nine project Hospital, and community2. Providing a seven day service. sites involved in delivering seven day neurology service or 45 minutes of therapy services. It is • The NHS Camden - stroke REDsThere were nine project sites who not presented as scientific research, teamparticipated in the project from both but service improvement work, with • Community stroke team inhospital and community measurement and comment Blackburn with Darwen,environments. accordingly. part of Lancashire Care NHS Foundation TrustEach site provided information on: Observations are included from other • South Tyneside NHS Foundation• Population sites across stroke and wider therapy Trust physiotherapy stroke team• Numbers of stroke patients services in England, and stroke • Medway Community Healthcare, referred therapy services in USA, Canada and the staff on the stroke rehabilitation• Type of service New Zealand. The publication includes unit at St Bartholomew’s Hospital,• Bed numbers (if applicable) some of the research evidence and Rochester, Kent• Staffing the results of a consultation with a • Chesterfield Royal Hospital NHS• Length of stay and/or functional wide range of relevant stakeholders. Foundation Trust acute stroke outcomes. unit team. Project teamsEach site also collected data on The organisations taking part in the For ease of reading, teams will beapproximately 30 patients. The projects were as follows: referred to by the emboldened titlessamples were not comparable and are above in the rest of the document.only a snapshot of each site. Only one • Sheffield therapy team, from thesite managed to collect data before Sheffield Teaching Hospitals NHSand after a change in service delivery Foundation Trusttook place. The data included some or • Sheffield speech and languageall of the following: therapy, from the Sheffield Primary Care Trust speech and language• Admission to treatment service into Sheffield Teaching• Frequency of treatment (i.e. how Hospitals NHS Foundation Trust often or on how many days therapy • The stroke unit at St Thomas’ was given) Hospital, Guys and St Thomas’ NHS• Intensity of treatment (how long the Foundation Trust treatment session was for)• Therapist opinion on frequency and intensity required• Reason for 45 minutes of therapy not being received• Staff, patient and carer satisfaction. 7
  8. 8. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation National guidelines NATIONAL STROKE STRATEGY - QUALITY STANDARDS FOR DEPARTMENT OF HEALTH STROKE - NICE “People who have had strokes access Quality Standard - 5 high-quality rehabilitation and, with their Patients with stroke are assessed and carer, receive support from stroke-skilled managed by stroke nursing staff and at services as soon as possible after they least one member of the specialist have a stroke, available in hospital, rehabilitation team within 24 hours of immediately after transfer from hospital admission to hospital, and by all relevant and for as long as they need it.” (Quality members of the specialist rehabilitation Marker 10: High quality specialist team within 72 hours, with documented rehabilitation) multidisciplinary goals agreed within five days. “Survival is strongly associated with processes of care… such as early Quality Standard - 6 mobilisation, early feeding and measures Patients who need ongoing inpatient to prevent aspiration. Speech and rehabilitation after completion of their language therapists, physiotherapists, acute diagnosis and treatment are occupational therapists and dietitians treated in a specialist stroke have specific contributions to make in rehabilitation unit. delivering these particular aspects of care. The probable explanation for Quality Standard - 7 higher survival and lower Patients with stroke are offered a institutionalisation rates (on stroke units) minimum of 45 minutes of each active are the significant differences in both therapy that is required, for a minimum multidisciplinary team working – such as of five days a week, at a level that early assessment, goal setting and enables the patient to meet their discharge planning.” (Quality Marker 9: rehabilitation goals for as long as they Treatment) are continuing to benefit from the therapy and are able to tolerate it. “Existing staffing numbers and skill mix profiles are insufficient to deliver the Quality Standard -10 required input in stroke care pathways. All patients discharged from hospital Workforce review is therefore needed, who have residual stroke-related along with a workforce plan that defines problems are followed up within 72 the care pathway, lists the functions at hours by specialist stroke rehabilitation each stage and the competencies services for assessment and ongoing required to perform the functions, and management. then ensures training is put in place to support staff to acquire the competencies. “ It recommends that services “consider new and more flexible roles (i.e. expanding roles across professional boundaries)” (Quality Marker 18: Leadership and skills) 8
  9. 9. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationNATIONAL CLINICAL GUIDELINE FORSTROKE, THIRD EDITION – ROYALCOLLEGE OF PHYSICIANSA) Patients should undergo as much therapy appropriate to their needs as they are willing and able to tolerate and in the early stages they should receive a minimum of 45 minutes daily of each therapy that is required.B) The team should promote the practice of skills gained in therapy into the patient’s daily routine in a consistent manner and patients should be enabled and encouraged to practice that activity as much as possible.C) Therapy assistants may facilitate practice but should work under the guidance of a qualified therapist.Further assessments can and should beundertaken later, and this set ofrecommendations focuses on those thatare important in the first 48 hours; toidentify major impairments that may notbe obvious but that may have aninfluence on early management, guideprognosis and draw attention toimmediate rehabilitation needs.“All patients with any impairment at 24hours should receive a fullmultidisciplinary assessment using anagreed procedure or protocol within fiveworking days, and this should bedocumented in the notes”. 9
  10. 10. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Who can deliver more rehabilitation? Flexibility and creativity about staffing What the stakeholders say KEY MESSAGES may be needed to deliver improved The general consensus from the rehabilitation for stroke patients. This stakeholders is that rehabilitation • A flexible and creative section describes the different assistants are a cost effective way of approach to rostering can approaches the projects took, and the ensuring that patients get a robust gain support from a wider impact. rehabilitation package, and may be pool of appropriate staff to essential to meeting both 45 minutes keep additional services What the evidence says and seven day therapy provision. sustainable and enhance The NICE quality standards define However services need to have clinical skills for therapists therapy services as physiotherapy, mechanisms in place to ensure that • Weekend services that include occupational therapy, and speech and these assistants have suitable acute and community staff language therapy. Individual patients supervision and support to maintain can assist with a smoother may require treatment from other the competencies required to follow transfer of care experience for professionals such as clinical professionally developed plans patient and carers psychologists and dieticians. They are effectively. • Additional rehabilitation relevant to all environments across the provided by a therapy team pathway. (3) Royal College of Other time consuming tasks such as has more impact meeting Physician (RCP) Guidelines state that completing outcome measures, required standards than when therapy assistants may facilitate the delivering equipment and some it is delivered by suitably practice but should work under the administrative tasks could be trained nurses guidance of the qualified therapist. (2) delegated to rehabilitation assistants • Stroke skilled support workers to free up qualified therapists’ time. can assist therapy services Practice outside the UK with achieving 45 minute In the US, state-funded Medicare The stakeholders also suggest that to therapy sessions and seven requires specifically physiotherapy, achieve both the access to seven day day services and are integral occupational therapy, and speech and services and 45 minutes of therapy, to achieving the NICE quality language therapy are delivered, but teams should take a more integrated standards services such as psychology are not approach to rehabilitation. Therapists • Joint working with nurses has included. Therapy services can be should increase involvement with the a positive effect on cohesion supported by rehabilitation patient and the wider team, and and compliance and can be technicians for administrative who where appropriate should include achieved in addition to direct support work and are not directly nursing staff and the family in therapeutic clinical contact involved in the provision of therapy promoting a continuous rehabilitation time services. Qualified occupational culture. This can also support the therapy assistants and physical patient towards self-management in therapy assistants may provide the longer term. therapy services directly to patients under the appropriate supervision of licensed therapists, and families are very engaged.10
  11. 11. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationProject findings The South Tyneside physiotherapy This model enables the service toThe stroke unit at St Thomas’ stroke team provided a weekend meet the NICE quality standards 5 andHospital offers an additional service for the stroke unit, by 6, the National Stroke Strategy andweekend rehabilitation service that is recruiting an additional band 5 the RCP guidelines for physiotherapy.provided by rehabilitation support physiotherapist and band 4 technical Their admission to assessment timeworkers who work as healthcare instructor to work five days improved from 52% within 72 hoursassistants during the week. The comprising three during the week and (2008) to 93%.content and structure of the weekend two at the weekend. They solved theprogramme is selected by the recruitment challenge by including the The South Devon team on the stroketherapists from an ‘options menu’. post within the existing band 5 rehabilitation unit at Newton Abbot rotation scheme, and gradually rolled Hospital reallocated existing fundingWhilst the 20 minute sessions the out the changes in contracts with for the band 5 physiotherapy post torehabilitation support workers provide each new member of staff. fund three band 3 rehabilitationdo not meet the NICE quality support assistants and four hours of astandards or RCP guidelines To ensure competence, supervision band 6 occupational therapist orspecifically, they do demonstrate a and support the band 5 therapist can physiotherapist for Saturday. Theproactive multidisciplinary approach to liaise with the on call therapy team at additional rehabilitation supportrehabilitation, and support workforce weekends, and is supported during assistants are rostered from Saturdayflexibility. Patients have a greater the rest of the week from within the to Tuesday, and the qualified staffnumber of rehabilitation contacts stroke team. The stroke team act from a rota of stroke skilled therapistsduring admission, but not therapy pragmatically and flexibly when there from the team and communitydirect contacts. Therapists feel that is a vacant post to provide a six day service.patients who use this service maintain service from within the existing staff.better ‘carry over’ for Monday than Their new model demonstrated anthose who do not. Since the inception of the project, improvement in admission to many more patients have received 45 treatment time, with 100% of minutes of physiotherapy, and therapy patients being assessed within 72 has been provided at the weekend. hours compared to 80% in 2008. All appropriate patients were able to access 45 minute treatment sessionsPercentage of patients seen for 45 minutes of therapy compared to 92% in 2008. Feedbackbefore and after the changes in South Tyneside from patients and carers was already very good, but had highlighted a wish for more therapy opportunities. Before introduction of Since August 2009 Since August Since Aug 2009 project (week days) (week days) 2009 average daily (weekends) (seven day) Staff felt that communication between hospital and community 33.8% 75.6% 68% 68% services, and appreciation of the transfer process for patients, improved. It also meant that weekend staff had a reasonable frequency of shifts to maintain their work-life balance, and enabled community therapists to keep their acute rehabilitation skills up to date. 11
  12. 12. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation The benefits for the patients, service In Blackburn with Darwen, the Assistant support staff, backed up by and carers with the new model community stroke team have competency based education, can outweighed the disadvantages of the established support links with a pool enable therapy services to improve loss of a band 5 rotational post on the of rehabilitation support workers and assessment time, and 45 minute service. intermediate care support staff which therapy sessions, more readily than enables them to provide 45 minutes healthcare assistants (Blackburn with In Sheffield Teaching Hospitals NHS of therapy, daily and for as long as Darwen community stroke team). Foundation Trust the occupational needed to meet NICE quality This is because of their contribution therapy and physiotherapy services, standards. Their data showed that within the team across seven days. moved from five to seven day services most of the 45 minute sessions were Healthcare assistants can bring as part of a major change across delivered by the rehabilitation different benefits, such as a greater therapy teams. The stroke service assistants with varied support from understanding of the rehabilitation included an ‘away team’ comprising qualified therapists. process when delivering nursing therapists from neurosciences, spinal care.(St Thomas’ Hospital). injuries and neuro-rehabilitation Summary services and a ‘home team’ All the models demonstrated higher The Sheffield therapy team project comprising staff from the stroke team. patient and carer satisfaction, but only demonstrated the challenges faced those that included additional when taking therapy staff with It was felt that although there were qualified staff were able to impact on common core neurology skills into a commonalities of clinical skills, the assessment time and the NICE quality different environment and the need to transposition of staff into a different standards. Traditional concerns around support and manage this carefully. In geographical location, with unfamiliar using band 5 therapists and sufficient South Devon a creative and inclusive equipment, protocols, documentation supervision at weekends were avoided approach to rostering meant weekend and profiles, required considerably by the South Tyneside model and in staff had the reasonable frequency of more adjustment and settling in time South Devon the loss of the band 5 shifts to maintain a work/life balance than had been anticipated. With up to was outweighed by the gains. No and enabled community therapists to 28 staff within therapy services model impacted negatively on keep their acute rehabilitation skills up working on a weekend a robust recruitment, supervision, retention of to date. support system was required which staff, or length of stay. included the rostering of a duty manager for therapy services at weekends to support staff and deal Sheffield Teaching Hospitals NHS Foundation Trust - with any staffing problems. Ability to deliver 45 minutes Before the seven day service, 100 Sheffield OT Sheffield PT physiotherapy and occupational 90 therapy were able to provide access to 80 45 minutes of therapy for 76% of the time, on average, for appropriate 70 patients. Post implementation this Percentage 60 increased to 92% for physiotherapy 50 and 91% for occupational therapy. NICE quality standards 5 and 6 were 40 achieved. The recommendations of 30 the National Stroke Strategy around 20 vital signs and early access to therapy, 45 minute sessions and delivery of 10 RCP clinical guidelines improved. 0 Pre seven day Post seven day12
  13. 13. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationWhere teams instigated specific jointworking, there were initialreservations from some therapy staffthat their skills would be diluted.However, it was found to havepositive effects not only on thepatients and nursing staff directly, buton compliance with therapytimetabling, as therapists still had timeto undertake their specific and highlycomplex therapy work. Joint workingmay improve communication; byworking in tandem, information ispassed on and there is less timewasted. In addition, there is greaterconsistency with handling and movingpatients, an area often highlighted asa concern by patients. 13
  14. 14. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation When - a seven day service? This section looks at the frequency of Practice outside the UK KEY MESSAGES rehabilitation required to meet NICE In the US, state funded Medicare quality standard 7 to offer therapy services adopt the ‘three hour rule’ - • Weekend therapy services input ‘for a minimum of five days a three hours a day of physiotherapy, impact on service delivery week’; and the potential alternatives occupational therapy and speech and across the whole week for delivery of additional services. language therapy five to six days a positively week. The staffing ratio is 7:1 patient: • Seven day services can have What the evidence says therapist each day, supplemented greater impact than six day Studies in US rehabilitation centres with administrative rehabilitation services found that factors such as function at technicians. • Additional days of therapy admission, length of stay and intensity services have a positive effect of therapy collectively contributed to In addition to this there are one to on admission to treatment greater functional gains, but length of two hours daily of occupational times and 45 minutes of stay and intensity of therapy alone did therapy or physiotherapy group therapy not always [Chen et al] (20) sessions and weekly speech and • Seven day therapy services cognitive group therapy sessions. enable patients to begin their A single study found moderate treatment as early as possible evidence that the same therapies In Canada, the requirement is for a • Seven day community stroke delivered more intensively, over a minimum of one hour of direct services can influence hospital shorter period of time, resulted in therapy for each relevant core therapy, length of stay and vital signs faster recovery and earlier discharge for a minimum of five days a week positively and more from hospital [Teasell et al] (5). based on individual need and significantly than single tolerance. (10) therapy weekend inpatient A trial conducted in Japan compared services outcomes for stroke patients admitted What the stakeholders say • Patients and carers welcome to a conventional stroke rehabilitation Access to therapy, and therapy additional rehabilitation programme five days per week and assessments, should be consistent and opportunities at weekends patients admitted to a programme continuous within rehabilitation seven days per week. The intensity settings across seven days. In turn, and frequency of treatment varied patients are more likely to respond between the programmes and better to therapy, avoiding a loss of patients were encouraged to remain momentum over a weekend and active outside of the structured therapists could have more capacity to sessions. Additional weekend therapy offer 45 minutes of therapy. Some resulted in significant improvements in stakeholders felt that patients need to FIM1 scores as well as a reduction in have a day of rest and reflection, and length of stay. [Sonoda et al] (21] they agreed that patients risk losing [Teasell] (5). out if this happens on a week day and no weekend service is available. 1The Functional Independence Measure (FIM) scale assesses physical and cognitive disability, focussing on level of disability, the burden of care.14
  15. 15. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationProject findings Qualitative data indicated that all In Chesterfield Royal Hospital, theIn South Devon, the additional speech and language therapists seven day physiotherapy service onservice over the weekend enabled involved in the pilot felt that they had the acute stroke unit found thatpatients to have an increase in impacted positively on patients by although they did not reduce lengthnumber of sessions. This also having this service, and 50% felt of stay significantly, there was aimpacted positively on the team’s happy to be working at a weekend. gradual process of setting dischargesability to deliver 45 minute sessions. The team noted that there seemed to for earlier in the week than before.Patients’ length of stay was already be more clinical need for dysphagia They commented on an improved feelimproving and could not solely be assessment than dysphasia treatment. to Mondays due to the reducedattributed to the additional weekend pressure to catch up with the backlogservice. In the Sheffield therapy team, funds from the weekend. were provided for seven day workingFor the South Tyneside team, the across orthopaedics, stroke, ‘front of Blackburn with Darwen communityseven day physiotherapy service door’ and respiratory services. The stroke team and NHS Camden -assessed all patients within 24 hours additional service for stroke comprised stroke REDs community strokeand delivered 45 minute sessions an occupational therapist, a teams both operate through awhere appropriate, although length of physiotherapist and two assistants multidisciplinary ‘in reach’ model andstay was not significantly altered. The who took their time back from provide occupational therapy,team agreed that to do that a similar existing services in the week. physiotherapy, speech and languageservice from occupational therapy therapy five days a week andwould be needed. At the weekend patients were ‘enabling care’ (rehabilitation support prioritised according to four criteria: through suitably trained social careThe Sheffield speech and language staff) seven days a week. They meettherapy team piloted Saturday 1. To facilitate discharge NICE quality standards 7 and 10, themorning working over three months 2. Eligibility for existing ESD RCP guidelines and quality marker 10on the acute stoke unit. The service 3. New patients (rehabilitation) quality marker 12was provided by band 6 and 7 speech 4. Other rehabilitation patients (transfer of care and health and socialand language therapists, from a roster care joint working) and quality markerof paid volunteers. In the pilot they The team noted that the effect of 19 (workforce) of the National Strokefound, from a small sample size, that seven day working within stroke Strategy. NHS Camden - stroke80% of patients referred to speech seemed to be stronger for facilitating REDs data showed a significantand language therapy were seen discharge. Their data showed a contribution to reducing length ofwithin 24 hours, 25% of patients positive impact on admission to stay in the acute hospital, now downrequired daily speech and language assessment times from 62 hrs to 10 days, and demonstrated to localtherapy at some point in their stay, (occupational therapy) and 47.4 hours organisations the contribution ofbut not consistently across their whole (physiotherapy) pre change, to 25.6 comprehensive and responsiveinpatient spell, and more than 50% hours for occupational therapy and community stroke services torequired 45 minutes on some days. 30.4 hours for physiotherapy post resolution of acute challenges. change. 15
  16. 16. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Summary through whole pathway change, The project teams reported that the when all services operate across seven biggest impact of a seven day service days. Single professional changes, in was on admission to treatment time one part of the pathway only, are and the ability to provide an equitable unlikely to have a significant impact service. Once this had occurred, they on length of stay or cost benefits for found that the whole working week an organisation. (South Tyneside). began to change too, and therapists However, they do have a positive could offer more contact time. effect on satisfaction levels, speedier access to assessment and frequency Services across seven days moved and intensity of sessions for those closer to achieving the NICE quality patients who can tolerate it. standard than six day services. Findings of teams from Medway Patients also value opportunities for Community Healthcare and York more therapy across the pathway. Hospital NHS Foundation Trust in the Therapy services may consider national projects 2009 - 2010 who developing seven day services as a first delivered a six day therapy service step towards achieving 45 minute improved admission to treatment therapy sessions, because of its impact time, but could not achieve 100% on intensity as well as frequency. (25). Seven day services in South Tyneside and Chesterfield Royal However, any opportunity to enhance Hospital achieved this standard. This rehabilitation, by weekend sessions is likely to be due to a removal of the from suitably trained healthcare weekend backlog of outstanding assistants (St Thomas’ Hospital) or, assessments on Mondays, freeing up by joint working (Medway more time each day to allocate for Community Healthcare and South direct treatment and the effect of a Devon) or by having an additional seven day presence on presence (Sheffield speech and communication between the language therapy) can bring benefit; multidisciplinary team, and with either for multidisciplinary team patients and carers. Models that used cohesion, mutual support, and existing therapy staff differently or education or simply improving over more hours in the week found communication and reducing the more opportunities to deliver a greater need for additional documentation. proportion of 45 minute sessions and for joint working than in five days. The findings of the projects show that, once established, the culture of a seven day service facilitates more timely decision making. (Chesterfield Royal Hospital) It has the potential to shorten length of stay16
  17. 17. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationHow long - getting more outof the whole week?This section deals with the intensity of For example, one survey observed that What the stakeholders saya patient’s therapy, meeting the NICE a significant treatment effect was Stakeholders indicated that therapyquality standard of 45 minutes. achieved among studies which should be available to patients as early provided a mean of 8.8 hours of as possible once they are medicallyWhat the evidence says therapy per week for 11.2 weeks stable, and commented thatThere is evidence to show that higher compared to trials that only provided psychology should be includedintensities of treatment can impact approximately two hours per week for because if problems are leftsignificantly on outcomes, activities 22.9 weeks. [Bhogal et al] (24). One unattended, they can become worsefor daily living and reduce study that looked into the benefits of over time. Some suggested that if inimpairments. [Langhorne et al] (7) aphasia therapy reported problems the early stages some patients are[Kwakkel et al] (11) Patients may not with patients’ tolerance of intensive unable to tolerate a single 45 minutesbenefit equally, which makes specific therapy. However, patients who session, services can deliver multipleguidance about intensity of received an average of 1.6 hours of shorter sessions over the course ofrehabilitation therapy harder to therapy per week had significantly one day.provide. [Duncan et al] (9). higher scores than those who receivedMany therapists express concern only 0.57 hours of therapy. [Bakheit et If two therapy staff are involved in aabout how many patients can tolerate al] (23). joint session and are working on45 minutes of therapy. However, different aspects of therapy, and thephysiotherapists have been shown to Practice outside the UK session is goal directed, then this canoverestimate the duration of therapy, Canadian guidelines state that be counted as two sessions.and that intensity of treatment is also “Patients should receive the intensitydependent on the ability and the and duration of clinically relevant Stakeholders don’t yet agree whatwillingness on the part of the patient. therapy defined in their individualised constitutes 45 minutes of ‘contact’[Teasell et al] (5). rehabilitation plan and appropriate to time. For the first time therapists have their needs and tolerance levels.” been given a treatment timeGreater benefit may be achieved if (intensity) guide of 45 minutes buthigh-intensity therapies are provided In the US, a patient must be able to need to maintain a level of flexibilityin the early stages of rehabilitation. safely tolerate the level of within this to accommodate patient[Teasell et al] (5). rehabilitation therapy programme individual needs. Some therapeutic provided in an inpatient rehabilitation interventions, such as psychology, mayThere is not conclusive evidence that unit. The intensity of therapy provided not fit well with a rigid time frame.more intensive speech and language must further the patient’s progress in Some academic stakeholderstherapy is better than less intensive meeting goals, rather than setting the commented that services should betherapy, although for patients who patient back by overtaxing them. offering ‘up to’ 45 minutes. However,can tolerate it, more intensive therapy Publicly funded stroke rehabilitation other front line stakeholders felt thatappears to result in improved facilities do not receive payment anything less than 45 minutes mightoutcomes. [Teasell et al] (5). On unless they provide at least three be limiting and therefore lessaverage, positive studies provided a hours a day of therapy, 55 minutes of effective. This may be due to thetotal of 98.4 hours of therapy while one-on-one therapy sessions with differences in definition of whatnegative studies provided a total of physiotherapy, occupational therapy counts towards ’45 minutes of43.6 hours of therapy. and speech and language therapy. If therapy’ and the debate around the patient is unable to tolerate this, direct/non-direct therapy. then it should be given in two 30 minute sessions. (6) 17
  18. 18. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Some people have started to refer to therapy, yet the same patient group KEY MESSAGES the amount of time a patient has for had least success as recorded by the • Patients do not all benefit therapy as the ‘dose’, to start to goal attainment scale. They equally from access to 45 formalise the requirement for a set recommend that therapy services minute therapy sessions amount of therapy time to be should adopt a menu of outcomes, to • In the community, patients available per patient, per day. inform service development. with more severe disability improved most with access to Stakeholders felt that access to both Using the NICE clinical standard of 45 45 minute therapy sessions 45 minutes of each therapy and seven minutes of therapy per day, five days a • Patients’ need for, and day services should reduce length of week, each patient should get 990 tolerance of, 45 minutes can stay through faster completion of minutes of therapy over the six weeks fluctuate, so services need assessments, more time for discharge they are with the team. The team to be sufficiently flexible and planning, faster improvements in found 17.5% of patients achieved the responsive to meet this mobility, activities of daily living, and required amount of therapy from • Joint working with nurses has patients managing at home more physiotherapy, 21.5% from a positive effect on cohesion quickly. occupational therapy and 11.1% from and compliance and can be speech and language therapy. Those achieved in addition to direct Project findings patients who received 990 minutes of therapeutic clinical contact NHS Camden - stroke REDs agreed occupational therapy and time local definitions and clarified contact physiotherapy had an average • Multiple 45 minute episodes and non contact activities for their increase in their Barthel scores of 6.4 by individual disciplines during service and the team reviewed data points, compared to an average a day may be difficult for a for 91 patients across six weeks of increase of 3.4 points by those who patient to manage; combined, rehabilitation, comparing the intensity didn’t and an average increase in their goal orientated visits work of therapy received using valid clinical Nottingham Extended Activities of • Staff may need to collect data outcome measures. The data showed Daily Living (NEADL) scores of 12 to challenge their own that patients with lowest Barthel points, compared to 10 points for assumptions about why scores had the greatest need of, and those who didnt. services are not being benefited most, from access to provided, to be sure it is because patients cannot tolerate it, and not because of NHS Camden - stroke REDs - the ability of the service to 45 minutes - impact on Barthel score points gained provide it • Services that operated over 35 Met Not met seven days had more success 30 in meeting the 45 minute guideline 25 Percentage 20 15 10 5 0 0-2 2-4 4-6 6-8 8-10 10-12 12-14 14+18
  19. 19. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationThere is a significant difference withthe Barthel outcome measures, when NHS Camden - stroke REDs- Reasons for not receiving 45 minutes of therapycompared with the sample of patients Declined daily therapywho get least therapy in terms of time Clinically not required(intensity) and number of visits No SLT required(frequency). At the start of No occupational therapy requiredintervention the Barthel for this group No physiotherapy required No staff capacitywith most amount of therapy is lower. Patient unavailableThis suggests that people, who Patient fatiguedreceived the most therapy in terms of Patient refusedintensity, were functioning at a lower Patient poorlylevel, based on the Barthel (average 0% 10% 20% 30% 40% 50% 60%score of 11.8)Regarding progress and change in theBarthel scores, this group of patientsmade significantly larger gains ‘Continuing to benefit’ and ‘able to tolerate’ should be(average of 6.3) when compared tothose who received the least amount defined jointly by both patient/carer and MDT.of therapy.The team make joint decisions with ‘Therapy time’ is anything related to person focussedthe patient about what level of rehabilitation facilitated by a specialist stroke practitionerintensity is appropriate for them. They and evaluated using clinical outcome measures.collected data to determine thereasons why 45 minutes of therapy NHS Camden - stroke REDswas or was not achieved for eachpatient. Thirty percent of patientsreported fatigue as a major factoraffecting ability to participate in an 3. Non-manageable at home – ranging from 14 – 49 days of 45intensive therapy programme at residential intermediate care bed minutes of therapy, two to three timeshome. For many patients there were with CST therapist support each day, over seven days. Patients onmultiple reasons why 45 minutes of 4. Residential/nursing care – CST core pathway one with mild and minimaltherapy was not achieved. team visit on discharge to check disability required much less intensive correct patient management. therapy. People in care homes mayBlackburn with Darwen community need 45 minute sessions of therapystroke team focuses on meeting They defined therapy for their service each day to improve a particular task.patient need rather than just early locally, and analysed a database of 20discharge for people in both hospital patients to determine which patients On the whole, there were more 45and community through four needed or benefited from 45 minute minutes of therapy contacts frompathways of support. sessions, and from which therapies, rehabilitation assistants with varied and examined the range from each input from therapists. Patients with1. High functioning – home with core therapy and the service. moderate to total dependency team support only (Barthel) received most input from2. Lower functioning but manageable They found that not all patients support workers and intermediate at home – home with community needed 45 minutes of therapy each care support staff, enabling the stroke team (CST)therapists and day, and that the need varied greatly. community stroke team to provide 45 domiciliary rehab team support Patients with moderate to severe minutes of therapy daily for as long as levels of disability (pathways two to needed. four) needed a level of support 19
  20. 20. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Local definition of therapy Any assessment or treatment provided by the qualified therapist from the community stroke team (CST) including physiotherapy, occupational therapy or speech and language therapy. Any therapy intervention which is part of the programme set by CST qualified staff and carried out by our rehabilitation support workers, on one of our pathways. Blackburn with Darwen community stroke team Blackburn with Darwen community stroke team - retrospective data on therapy need and provision Average Range Average days 45 Range Average other Range length of stay minutes therapy 45 minutes days in service from core stroke from support team service Pathway 1 131 22 - 265 50 1 -149 Pathway 2 175 110-243 68 52-97 43 40 -49 Pathway 3 141 84 -195 42 41-69 29 14 -42 Pathway 4 220 43 - 574 86 9-225 38 38 The Sheffield speech and language The South Devon team, as part of a against the percentage that received therapy team initially questioned demand and capacity exercise, 45 minutes per therapy group across whether 45 minutes would be right showed that they had only small all project teams. for each patient and whether their numbers of patients who could service needed to be more flexible to tolerate 45 minutes of each active Those who were assessed as needing deliver it. The project enabled them to therapy for five days a week and that 45 minutes of therapy, tended to get identify that 25% of patients required they had a surprising number of it when the services were increased. daily speech and language therapy refusals due to fatigue. Within the therapies, speech and intervention and over 50% needed 45 language therapy is suggested as the minutes on certain days. The pilot was The issue of judging whether a patient area where it is hardest to meet not long enough to demonstrate continues to benefit and/or is able to assessed need. whether daily availability of speech tolerate remains a subjective and language therapy could impact assessment on the part of the on adverse effects for patients, e.g. therapists. The scatter plot, taken incidence of aspiration pneumonia, from data from the projects, shows but staff found that being available on the percentage of patients thought to a Saturday had a positive effect on benefit from or tolerate 45 minutes patients.20
  21. 21. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Seven day working enabled the work Numbers of patients who could tolerate 45 minutes of therapy to be more equitably spread across a week, which meant there were more 100 opportunities to achieve 45 minute % 45 minutes delivered therapy sessions (Chesterfield Royal 80 Hospital, South Tyneside, and South Devon). 60 Some of the teams’ initial 40 preoccupation with attempting to define the detail around 45 minutes 20 issues translated into attention to methods of changing the shape of 0 their service, and the ways in which 0 20 40 60 80 100 they worked, so that they could % assessed as needing 45 minutes of therapy deliver: SLT OT PT • More hands on treatment each day • A flexible response to patient need • More opportunities for therapy in a variety of forms.Summary In the community, patients with moreThe project teams’ findings mirrored severe disability improved most with Focussing more on improving serviceinternational guidance around access to 45 minute therapy sessions. delivery may better enable therapytolerance and therapy. NHS Camden services to provide a service that- stroke REDs and Blackburn with Where therapy services collected data meets national guidelines and be ableDarwen community stroke team data for when a 45 minute treatment to offer the right therapy at the rightallowed detailed analysis of allocation session occurred, and if not, why not, time, for the right reasons to the rightand uptake of the 45 minute sessions. it offered them valuable insight into patients as and when they canIt supported the research findings that their reasoning processes and fixed tolerate it and need it.one size does not fit all and of the assumptions that may be derived fromcomplexities created by organisations practice or working to prioritisation The project findings demonstratedand priorities. protocols. Some teams at each stage that ‘therapy’ relates to allied health of rehabilitation reported that more professions, including assistants, butTheir pragmatic approach based patients could tolerate 45 minutes if that any opportunity to enhanceon thorough assessment, good it was available and the data showed rehabilitation, either by weekendmultidisciplinary team communication, that where it was not possible to sessions from suitably trainedshared skills and competencies, deliver it, it was often due to the healthcare assistants (St Thomas’involving the patient and carers and service organisation. This suggests Hospital), by joint working (MedwaySMART (Specific, Measurable, that services might learn from Community Healthcare and SouthAttainable, Relevant and Timely) undertaking demand and capacity Devon) or by having an additionalmultidisciplinary team goals enabled exercises and reviewing their practice presence (Sheffield speech andthem to avoid unnecessary and processes, before making language therapy) can bring45 minute sessions without changes in staffing, or requesting benefit.compromising outcome and additional resources, endorsed by thepreventing fatigue for people at findings of Medway Communityhome. This information is also Healthcare.valuable to inform the commissioningservices, and developing resources. 21
  22. 22. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Where can more therapy make a difference? Projects were drawn from across the Project findings KEY MESSAGES stroke pathway and demonstrated The Chesterfield Royal Hospital that seven day services had a benefit team provided a seven day • Patients can benefit from in all settings. physiotherapy service on an acute access to seven day therapy stroke unit. Data showed services in all settings across What the evidence says improvements in NICE quality the pathway The Collaborative Evaluation in Stroke standards 5 and 6 and the RCP • The benefits and opportunities across Europe (CERISE) studies guidelines for physiotherapy from seven day therapy conclude that whilst there is evidence assessment times. There was no services vary along the for the positive effect of intensive significant effect on length of stay, but pathway, reflecting the task-specific exercise on the functional some individual reductions, which different needs of the patient recovery of stroke patients, stroke suggested planning discharges earlier • Individual requirements for 45 rehabilitation units in the UK are not in the week was having an effect. minutes of therapy can vary organised to optimise the amount of during the course of their therapy given to patients. Included The South Tyneside, Medway, journey along the pathway, within this are aspects of environment South Devon and Sheffield therapy not just depending on their and culture, organisational priorities, teams delivered their additional medical status, but also on different healthcare systems with their service on a stroke rehabilitation unit. their goals different barriers and incentives to The South Tyneside unit is now able • Therapy support workers can change, case mix and admission to achieve the NICE quality standards assist with successful delivery criteria. [Putman et al] (13,15) 5, 6 and 7 and RCP guidelines for of 45 minutes and a seven day physiotherapy and have identified that service at all stages However, it may also be worth noting the next stage is to develop the that although in international occupational therapy service. In South comparisons, UK stroke units had the Devon and Medway Community lowest therapy contact time and best Healthcare, the teams are working to The Blackburn with Darwen and staffing, they also had rehabilitation identify how to improve the service NHS Camden - stroke REDs units with the least exclusion criteria further to be able to offer additional community teams both have robust and decisions about therapy for opportunities for therapy, by data collection systems. This supports patients were more often made by reviewing their use of non contact extensive analysis which enables them clinicians. time, and developing sustainable to identify the effect of 45 minutes of group work. therapy on clinical and service What the stakeholders say outcomes. This has resulted in Stakeholders felt that seven day The Sheffield therapy team reflected improved multidisciplinary team goal services should be available across the on the experience and their data and setting, predicting outcomes and pathway from hyperacute to early identified some questions for further devising effective packages of supported discharge teams in the discussion locally about organisation intervention on an individual basis, community, where patients continue and distribution of therapy resources maximising the use of their skill mix. to benefit. along the stroke pathway. They are both able to demonstrate a positive financial impact on the acute Patient feedback in the Sheffield service through reducing length of speech and language therapy stay, and for social care by reducing project indicated that during the acute final packages of care. Blackburn stage of the pathway they want to with Darwen community stroke receive a seven day service, but are team (2010) reduced final packages less keen when they are back at home of care per week by 240 hours of as they welcome a break at care/week, equating to £93,600 weekends. savings per year.22
  23. 23. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationSummary In the community, therapists wereThe project teams crossed the able to look at resolving the challengepathway from hyperacute stroke unit of overloading the patients withto community teams, and in all cases excessive visits through developingthey made a difference. shared competencies and multiskilled staff delivering goal orientatedHowever, in each setting, additional sessions (NHS Camden - strokeservices bought other, slightly REDs and Blackburn with Darwendifferent gains too, reflecting the community stroke team).stage of recovery and different needsof the patients from each Feedback from carers, and other staffenvironment. was positive regardless of location.In South Devon and Medway Seven day therapy services have aCommunity Healthcare, the teams value in all settings across thehad developed joint working with pathway; specifically to deliver equitynursing staff and were considering of access to assessment and, wheregroup work. This is probably more these exist, the project teams found aviable and sustainable on a stroke positive effect on direct contact timerehabilitation unit than in an acute and 45 minutes of therapy.stroke unit where the focus was moreon developing an equitable serviceacross the week, and facilitatingspeedier and smoother transfer on(Chesterfield Royal Hospital, SouthTyneside and Sheffield therapy). 23
  24. 24. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation How - bridging the gap? ”The gap”- themes from the research Collaborative Evaluation in Stroke across Europe (CERISE) studies have shown that stroke patients in the UK spend much less time engaged in therapy than in European rehabilitation units. Findings for the UK suggest one hour a day, compared with three in Switzerland. In all centres, physiotherapy comprised nearly 40% of therapeutic time, but occupational therapy comprised 20% - 30%, except in the UK unit where it was 11.6%. In the UK, 35% of therapy time consisted of nursing care. After correction for case-mix, overall therapy time in the UK unit was significantly less than the other countries, and the differences in therapy time were not attributable to differences in staffing. [De Witt] (14) (16) (17) In a more recent study, therapy some significant difference in content. However, stakeholders and some staffing levels were comparable with They refer to the ‘black box’ of therapy services reported challenges existing literature, yet there was wide challenges around understanding and embedding group work within stroke unexplained variation in contact time measuring what therapists do; such as unit routines for various reasons, with the patient. Seventy five percent lack of reporting the detailed including lack of time, staff availability of patients received less than an hour characteristics of the interventions, to transport patients and difficulty of therapy, and 25% less than half an the complexity and diversity of gaining sustained nursing support. hour of any therapy each day. The interventions and the potential range lowest levels of therapy input were of different approaches used, along Develop a seven day from speech and language therapists, with the practice adopted by rehabilitation culture with only 25% of patients having any therapists of reliance on clinical Project teams in the community contact with a therapist, and a experience rather than on theoretical (NHS Camden - stroke REDs and median contact time of 30 minutes. frameworks, and the overlap and Blackburn with Darwen community [Rudd et al] (19) blurring associated with joint working. stroke team) and on stroke [De Witt] (12) rehabilitation units (South Devon Part of the CERISE study explored the and Medway Community relationship between the content of One possibility for increasing contact Healthcare) have undertaken work therapy and the level of patient motor time is through group work. Recent specifically to develop their impairment, expecting the content of studies have also shown that the rehabilitation culture. therapy to differ in patients with efficiency of limited therapeutic different levels of motor impairment. resources can be increased by using They found significant differences in circuit training programmes in which a duration of physiotherapy and group of patients is allowed to occupational therapy sessions and practice at different workstations at the same time, under the supervision of a therapist. [Kwakkel et al] (8)24
  25. 25. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Understand the data KEY MESSAGES Both Blackburn with Darwen and • Develop a rehabilitation culture in your team NHS Camden - stroke REDs • Visit a successful site prior to making change to improve understanding community stroke teams have and support for the process locally established comprehensive databases • Consider a single management system for nursing and therapy which which enabled them to thoroughly can improve line management consistency, provide better coordination understand their services and and enhance stroke specialist clinical governance outcomes, especially around access to • Involve and include staff and establish good communication processes and delivery of 45 minute therapy • Be prepared for staff objections and manage these through good sessions. Their systems work communication processes alongside, and in addition to, local • Understand the team’s true demand and real capacity to improve databases which have limited ability to understanding, planning and control of the work, enabling more provide useful qualitative and therapy time to be offered. quantative information about therapy services. The initial additional effort required for data entry is outweighed by the benefits derived fromThe Medway Community The stroke service in the United comprehensive analysis of a person’sHealthcare team felt that the therapy Hospital of North Staffordshire progress through a pathway orculture should form the basis of the (UHNS) redesigned their services service.patient’s day. One way of achieving along the lines of the Trondheimthis was by partnering members of model in Norway following a visit to Manage the human dimensionsthe nursing and therapy staff during the unit. (26) They have a The Sheffield therapy project teammorning washing and dressing, and at rehabilitation ward with joint working was part of a bigger initiativelunchtimes. This integrated approach between nurses and therapists, with delivering a seven day therapy servicealso meant moving the therapy team joint ward rounds and assessments. across five clinical domains, with 26to a base on the stroke rehabilitation All the patient activities have a staff to cover the weekend strokeunit alongside the nursing staff. rehabilitation focus and treatment is service. It involved a major goal orientated rather than process consultation process includingProject teams in South Devon, orientated. Some tasks remain nursing meetings with stewards and humanMedway Community Healthcare tasks, and the therapists contribute resources staff to ensure clarity andand Sheffield therapy services towards these. equitable decision making.changed the start time for therapists Communication systems were put into enable them to work more To achieve this they reviewed therapist place, including a reference groupinclusively with nursing staff, and and nursing roles on the unit to with a collection of staff across allmore effectively support the patients’ promote blurring of boundaries, grades and all areas, which proved toroutine, fostering the rehabilitation focusing on the needs of the patient be a good barometer for staffculture. with family participation. Therapists experience and gave the manager now work solely on the stroke unit opportunities for regular and directWhilst not part of the original NHS and are managed by the stroke unit contact.Improvement - Stroke project, the manager. They have introduced newteam from the stroke service in Stoke- roles that do not have professionon-Trent undertook their own change related titles, but are focused onprogramme, addressing many of the rehabilitation. All staff work shifts,areas of interest to those looking to nurses 24 hours and therapists sevenenhance access to therapy. days, with band 2 staff alternating therapy and nursing rotas. 25
  26. 26. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitation Staff fed back comments during the Challenges and solutions in Sheffield process that were reviewed Teaching Hospitals NHS Foundation Trust immediately. Actions were planned and communicated to the teams Moving and handling: non stroke-skilled staff need time to develop through the team leads, then confidence and familiarity with the handing procedures, protocols and published so that everybody was issues for stroke. aware of the responses made. Training and in-service training sessions were Data collection and paperwork: simplify administration and provided as issues and concerns were measurement. Be clear about data collection systems and how the service raised. will be evaluated. The short time frame for Variation in assistants’ skills: capitalise on the enthusiasm and good implementation prevented the delivery will of those working most frequently in the service, and be prepared to of the thorough training plan that had support peripatetic and part-time staff. been envisaged, but orientations were Time and rosters for staff: establish a consistent start-time for provided, including tours of the unit, occupational therapy to better support nursing staff, enabling longer term clinical information and opportunities flexibility and consistency across all staff. Do this in stages, over the to ask questions and for shadowing. longer term. A duty manager worked each Staff engagement: Proper consultation is essential. It is particularly weekend to support the 26 staff important to focus on the benefits for the patients. across two sites. This enabled staff to have on the spot support, and showed a management commitment to weekend working. Some duty St Thomas’ Hospital team needed to Analyse your workforce and managers also contributed to the ensure that the rehabilitation support design for the future clinical workload at the weekend. This workers could be supported with the The NHS Camden - stroke REDs was a valuable learning experience to complexities of a dual role at service carried out a demand and help understand and manage the weekends, and recognised their capacity exercise to develop a realistic process of change and support staff perceptions of split loyalties as part of and appropriate business case for an but did have cost implications. both the rehabilitation and nursing early supported discharge service, Possible alternatives are to provide an staff. Initially all staff were trained, but which suggested a ratio of patient on-call phone support, or to allocate with turnover and staff migration, a contact and non-contact time of the responsibility of a site lead to a gap emerged. This was managed by 50:50. By using this ratio, supported band 7 or band 6 member of staff taking a shared responsibility by other crucial data, they could working at the weekend. approach within the multidisciplinary accurately identify the correct skill mix team, through incorporating the of staff and the model required. rehabilitation skills into the competency documents for all nursing Medway Community Healthcare and health care assistant staff. They undertook a demand and capacity gained the sign up to the concept exercise on the stroke rehabilitation from the team, adopting a different unit. Challenges they faced were uniform for rehabilitation support getting the staff to appreciate the workers at weekends and devolving concept of ‘true demand’, and responsibility to the band 6 nurse for understanding that the basic premise supervision and support for the behind the data collection was that all rehabilitation support workers during patients should get 45 minutes of their shifts. each therapy daily. By carrying out the exercise the team were able to26
  27. 27. Mind the Gap: Ways to enhance therapy provision in stroke rehabilitationre-examine their service objectivelyand find time within the schedule toallow the occupational therapist torun a weekly carer clinic. They werealso able to introduce therapytimetables on the ward with improvedcompliance and support from thenursing staff. The insights they gainedfrom the exercise were so useful thatit has been rolled out across theirentire stroke pathway.The South Devon team completed ademand and capacity exercise and asa result implemented group sessionsin the gym three times a week,timetabled to coincide with maximumstaff availability. They have allocated asenior member of staff on each daywith dedicated time to update ‘thebig pieces of paperwork’, includingdischarge summaries, overviewassessments and the continuinghealthcare screens. The remainingstaff can continue with the clinicalwork, confident that the paperwork isunder control. 27